Basic Information
| Provider Information | |||||||||
| NPI: | 1174584957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHUDERER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LISAC LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 642 DAMERON DR | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863012411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284455211 | ||||||||
| FaxNumber: | 9287768484 | ||||||||
| Practice Location | |||||||||
| Address1: | 642 DAMERON DR | ||||||||
| Address2: | WEST YAVAPAI GUIDANCE CLINIC INC HILLSIDE CD | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863012411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284455211 | ||||||||
| FaxNumber: | 9287768484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LISAC11381 | AZ | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | LPC10607 | AZ | X | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 739485 | 05 | AZ | MEDICAID |